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As part of the AmeriHealth New Jersey annual review process, we obtain data
from the Healthcare Effectiveness Data and Information Set
(HEDIS®) Quality Compass® of hospital discharges
and frequency rates of selected cardiac procedures to help evaluate utilization
for our AmeriHealth 65® NJ HMO and AmeriHealth 65 Preferred HMO
Medicare Advantage members. The results showed that utilization remains within
national and regional standards for most indicators.
HEDIS® rates must score between the 10th and 90th national
percentiles, as published by NCQA's Quality Compass, to be considered as
meeting the goal. Because utilization is typically higher in this part of the
country, as compared to the rest of the United States, the Plan may include the
10th and 90th Mid-Atlantic Regional percentiles as thresholds for appropriate
utilization when calculating its score.
Hospital utilization
Hospital utilization comparison of acute discharges per 1,000 shows that the
overall HMO rates remain within the relevant national or regional 10th and 90th
percentiles as the appropriate thresholds for over/under utilization. A
comparison of HEDIS® rates reports a decrease for all age groups
except AmeriHealth 65 HMO members ages 20 – 44, which increased.* A
three-year trend analysis also demonstrates inpatient utilization to be
decreasing overall.
Use of services
AmeriHealth New Jersey also measured the frequency of selected procedure
rates for cardiac angioplasty, cardiac catheterization, and coronary artery
bypass graft (CABG) according to age and gender. Based on a comparison of 2015
HEDIS® utilization rates with respect to established thresholds,
utilization for use of services for these identified indicators were within the
established threshold for most age/gender categories.
There was one indicator that was above national and regional thresholds:
angioplasty in males ages 85 and older. Rates are measured according to age
group and gender, and AmeriHealth New Jersey recognizes the probability of
unequal variance as an issue with the cardiac procedure rates.
For more information
To learn more about HEDIS®, visit our website to view Highlighting HEDIS® articles
that have been published in Partners in Health Update. These articles
are educational resources for understanding HEDIS® measures. If
you have feedback about the Highlighting HEDIS® series or topic
requests, please email
us.
*The member population in AmeriHealth 65 plans
includes all New Jersey residents who reside in the Plan service area, who meet
the criteria for managed care enrollment according to the Centers for Medicare
& Medicaid Services, and who voluntarily enroll into the Plan during their
eligibility period. Therefore, statistical data is collected for all adult
members, regardless of age, who are enrolled in the Plan.
HEDIS is a registered trademark of the National Committee for Quality Assurance
(NCQA). Used with permission.
Quality Compass® is a registered trademark of the National
Committee for Quality Assurance (NCQA).
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